Beyond simple agitation, beyond anxiety, the concept of excited delirium refers to patients posing a potential threat to both themselves and the providers trying to care for them. This may be due to underlying psychiatric disease or a toxicologic etiology, but regardless of the cause, these patients are often found in a hypermetabolic overdrive. Keep that point in mind when considering these patients – they may be violent externally, but internally, they may also be hyperthermic, acidotic, or rhabdomyoly…tic. As such, physical restraints may actually be more harmful than helpful, and the best thing – for both the patient and for providers – may be to pharmacologically cool the patient down, so to speak.
This is the reasoning behind the EMS approach to excited delirium, which starts with attempts at verbal de-escalation but will move to medication interventions if there is impending concern for safety. Standing Order permits paramedics to give adult patients a one-time dose of midazolam, 10mg, IM. If the patient needs additional medication (or is a pediatric patient), crews will call for further Medical Control Options, which include additional doses of benzos, or weight-based ketamine. Take a look at the table in the attached pdf that illustrates the available options to better understand what crews have available.
Lastly, two broad points to remember across all protocols. First, remember to practice good closed-loop communication with the paramedics when giving specific medication and dosage orders (eg, “Paramedic, you are approved for an additional ten milligrams of midazolam intramuscularly; please repeat back”) in order to avoid medication errors. Second, any administration of a controlled substance (opiate, benzo, ketamine, etc), whether by Standing Order or Medical Control Option, will eventually require a Tracking Number (found at the top of each page in the book - MMC-####) for administrative purposes. Please assist crews for this when requested.
That’s it for this week, but don’t fret, I’ll see you all again in just 7 days! www.nycremsco.org or the protocol binder in case you can’t wait that long.
Dave